Educational Methodologies
Student Use and Perceptions of Different Learning Aids in a Problem-Based Learning (PBL) Dentistry Course Tania M. Gerzina, B.D.S., M.D.S., Ph.D., F.R.A.C.D.S.; Rebecca Worthington, B.Med.Sc. (Hons), Ph.D.; Scott Byrne, B.Med.Sc. (Hons), Ph.D.; Catherine McMahon, B. Physiotherapy (Hons), B.A. (Psych) Hons., Ph.D. Abstract: First-year dental students in a new problem-based learning (PBL) course, the Bachelor of Dentistry (BDent) Program at the University of Sydney, Australia, completed the Study Process Questionnaire and two other questionnaires in this study. The study aimed to identify student perceptions of a written formative assessment and the helpfulness of various learning aids used to prepare for this assessment and preparing to be a dental clinician. Correlations between approach to learning and perceptions of assessment and learning aids showed theoretically expected associations. Surface learning was associated with students’ concerns regarding whether assessment items reflected curriculum content, a valuing of lectures as a learning aid, and low scores for theme sessions. Deep learning was associated with a perception that the assessment tested application of basic and clinical sciences and a valuing of both independent study groups and learning topics as learning aids. An achievement orientation to learning was associated with a valuing of formative assessment as a learning aid and an intention to modify study habits as a result of participating in formative assessment. The findings provide insight into student learning in a PBL context that will help teachers and curriculum developers better understand the value of teaching aids provided in the program and the impact assessment has on study styles. Dr. Gerzina is a Senior Lecturer and Associate Dean (Curriculum), Faculty of Dentistry, University of Sydney; Dr. Worthington is an analyst with the Commonwealth Attorney General’s Department, Canberra, Australia; Dr. Byrne is a Postdoctoral Research Fellow in the Faculty of Medicine, University of Sydney; and Dr. McMahon is a Lecturer, Department of Psychology, Division of Linguistics and Psychology, Macquarie University, Sydney, Australia. Direct correspondence to Dr. Tania Gerzina, Faculty of Dentistry, University of Sydney, 2 Chalmers Street NSW 2010, Sydney, Australia; +61-2-9351-8324 phone; +61-2-9211-5912 fax;
[email protected]. Key words: formative assessment, student learning, problem-based learning Submitted for publication 2/6/03; accepted 4/14/03
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n 1994 the World Health Organization recommended that dental education should be problembased, socially and culturally relevant, and community-oriented. These recommendations, among many other factors such as changed patterns in oral health, application of molecular and genetic research to dentistry, and an increasing rationalization of health management, prompted significant curriculum re-evaluation in dental education.1 In response, many dental schools around the world set about constructing new curricula that were more responsive to student learning and more sensitive to evaluation mechanisms. These new curricula moved to a more contemporary student-centered approach, utilizing flexible methods of teaching and learning that enabled development of dental clinical skills enhanced by self-assessment and criterion-referencing. Team-
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work and competency-based systems also characterize these curricula.2-4 Problem-based learning (PBL) in medical education originated at McMaster University in Canada in the 1960s.5 Since that time, many versions of PBL have arisen worldwide in a variety of fields and at different levels of education. The essence of the method is that students are presented with a clinical case around which other instructional experiences are based. The educational objectives of PBL include the structuring of knowledge for use in clinical contexts, the development of an effective reasoning process, the development of effective self-directed learning skills, and increased motivation for learning.6,7 The PBL approach aims to promote deep as opposed to surface learning in students. Biggs8 has characterized deep learning as embracing a need to engage
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meaningfully with a task, focusing at a high conceptual level. Surface learning, in contrast, aims to complete the task in the minimum time and effort, focussing on low engagement with content. In medical education, PBL, compared with conventional curriculum strategies, has been shown to enhance both transfer of concepts to new problems and integration of basic science concepts into clinical problems (that is, deep learning). This, in turn, enhances intrinsic interest in the subject matter, motivation, and self-directed learning skills,5 as well as stimulating a deep understanding of basic mechanisms and developing clinical reasoning.9,10 In fact, a number of studies in medical education suggest that PBL-trained students are better able to learn and retain information11,12 and to integrate basic science knowledge into a solution of clinical problems. Further, the educational context of PBL encourages students to use a more educationally desirable approach to their learning than do students in a traditional medical course. For example, two studies showed that students of a problem-based medical school scored higher on a deep approach scale and lower on a surface approach scale than students of traditional schools.13,14 PBL instruction also appears to have distinct cognitive advantages over non-PBL processes, with PBL students revealing a significantly greater use of hypothesis-driven reasoning and greater coherence in explanations relating to evaluation of a clinical case study.15 However, Patel et al. compared the ability of conventionally trained and problembased trained medical housestaff to write differential diagnoses and provide pathophysiological explanations.16 They found both groups provided an equal number of diagnoses, but that the conventionally trained group generated a greater number of accurate hypotheses. These authors reflected skepticism of hypothetico-deductive methods as a means of learning, but noted that a balance between abstract and practical knowledge was important. Overall, the literature supports the hypothesis that PBL courses provide some advantages in medical education over traditional courses in regard to the student approach to learning, self-directed learning, clinical reasoning, and other desirable educational outcomes. However, once in a PBL course, what factors affect students’ approach to learning and the quality of their learning experience? Very little research has been conducted regarding the student perspective on the PBL learning process and factors affecting their learning within this context. One recent study attempted to explore the relationships
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among attendance, tutor performance, small group function, intrinsic interest in subject matter, amount of prior knowledge, time spent on study, quality of the problems, and achievement.17 The primary finding of the study was that motivation of the student to commit to the PBL program was a potent determinant of achievement in PBL. The variables examined in this study relate very specifically to PBL tutorials and did not address assessment or learning aids provided in a PBL course to support the tutorial experience. The process of assessment has been shown in a number of traditional courses to be a powerful factor affecting the way students approach their study. Van Berkel and colleagues conducted a study that examined student study behavior in a problem-based health sciences curriculum in relation to different assessment procedures.18 Students were examined in two ways: i) progress tests, designed to cover a large body of knowledge allowing students to evaluate their knowledge at certain points in the curriculum; and ii) block tests, resembling the traditional method of course-bound examinations on a specific area. Block tests had an undesirable effect, promoting a reproduction-oriented study approach, and were associated, by students, with “the pressure and tension connected to a traditional exam-orientated program.” Achievement on block tests was determined by “aspects associated with effort and organization in study activity.” Progress tests lacked the driving effect of forcing the students to work hard and were not perceived by students as a means to trigger self-directed and interest-based learning, but favored “the kind of meaning orientated learning processes, aimed at in problem-based learning” in contrast to reproduction oriented learning. Van Berkel and colleagues concluded that a deep approach to learning was more effective than a surface learning approach with respect to achievement in progress testing. Consistent with recent world trends in dental education, the Faculty of Dentistry at the University of Sydney discontinued its five-year curriculum and, in 2001, introduced a new integrated four-year program to better provide for the future needs of the practice of dentistry. The new program employs a problem-based learning (PBL) approach to teaching and learning with an early clinical introduction to best serve the faculty’s educational goals.19 Among these goals are the fostering of problem-solving, selfdirected learning, and self-evaluation as the basis for reflective practice and life-long learning. Assessment is constructively aligned to goals of the curriculum
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and features formative and summative versions of both written and dental clinical competencies assessment. The progress tests described in the van Berkel study resemble the formative assessments given to first-year students in the dentistry program, which are modelled on those used in the Faculty of Medicine program at the same university. The written formative assessment consists of two papers: a modified essay question (MEQ) paper and a single best answer (SBA) paper. Both papers, in alignment with the clinical case focus of the PBL, present several clinical cases from which a series of questions stem. Firstyear students participate in their first formative assessment six months after commencement in the program. A peer-marking session immediately follows completion of the assessment; in it, students mark a fellow student’s script by comparison with a set of ideal and competent (so-called “minimum level of competence”) answers devised by question authors. Our study has two specific aims. The first is to provide descriptive data on student experience of the first written formative assessment and on students’ perceptions of the usefulness of learning aids. The second aim is to examine the relationships between student approach to learning (as determined by the Study Process Questionnaire) and students’ perceptions of formative assessment and of learning aids. The new B.Dent. program at the Faculty of Dentistry uses web-based PBL as one of its teaching methodologies in addition to lectures and clinical sessions throughout all four years of the program.20 PBLs run all year throughout each of the four years. Each PBL tutorial group consists of eight students and a trained facilitator. Supporting learning resources for the PBL cases include learning topics, which are essay-style summaries of the main curriculum concept in each PBL case, along with patient data records and diagnostic images. In years one and two, there are three weekly ninety-minute PBL tutorials focusing on the biomedical knowledge underlying health and disease in predominantly medical clinical cases. In years three and four, there are two weekly ninety-minute tutorials focusing on dental clinical cases. Students and facilitators are evaluated during these tutorials.
Methods Three questionnaires were used: the Study Process Questionnaire (SPQ)21 and two questionnaires developed specifically for this inquiry. The SPQ is a
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widely used measure of learning approach proposed to have three orientations: surface, deep, and achieving, each with a supporting strategy. The survey uses forty-two items with six subscales, and data are best fit by three second-order shared indicator factors and one higher-order deep-achieving factor. The first of the two questionnaires created specifically for this study concerned student perceptions of formative assessment. The second addressed students’ perception of the usefulness of the learning aids available to them in the PBL program, both in preparing for assessment and in preparing to be a clinician. Questionnaire items were derived from individual interviews with students, a subsequent structured focus discussion group, and a review of written student feedback on assessment and previous examination papers available from faculty records. Demographic information was also collected regarding student age, gender, and previous educational qualifications. These questionnaires were constructed based on student responses as described below. Six-point Likert scales were provided with responses ranging from 1 (strongly disagree) to 6 (strongly agree). Positive and negative items were counterbalanced. The first questionnaire consisted of sixteen items specifically addressing the written formative assessment as a learning aid (Figure 1). The second questionnaire concerned the perception of learning aids. Ten paired items assessed student perceptions of the usefulness of PBL tutorials, learning topics, textbooks, theme sessions, lectures, independent study groups, syndicate notes, clinical school days, online assessments, and written formative assessments as learning aids for a) preparation for assessment and b) preparation to become a clinician (Figure 2). Issues raised by students in the pilot study were used as a basis for a structured discussion group. This discussion group, made up of ten volunteer first-year students, explored student comments on the learning aids provided to them in the program and included questions such as: • What is learning? • What learning resources in the course do you find useful to prepare for assessments? • What learning resources in the course do you find useful to prepare you to become a clinician? • How do you use each resource? • What was positive/negative about the recent written formative assessment? • How have you changed your learning approach in the light of the last written assessment?
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Figure 1. Questionnaire: student perceptions of the written formative assessment as a learning aid
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Figure 2. Questionnaire: student perceptions of the usefulness of learning aids
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• Did you think the formative assessment helped your learning? • What did the MEQ formative assessment actually assess? (e.g., memorization of facts, critical reasoning) • What should the formative assessment assess? Responses of the students in discussion group assisted in the phrasing and content of questionnaires 2 and 3. For the first goal of the study, descriptive statistics were compiled regarding student demographics (gender, age, and first degree) and student perceptions of their first experience with formative assessment and of the usefulness of various learning aids in using percentages. Data were entered into SPSS (Statistical Package for the Social Sciences) and analyzed. Correlational analyses (Spearman correlation coefficient and a significance level of p 85 percent agreement) as being useful for assessment preparation. This is expected since a large amount of course content is provided to students through these aids, and students are already familiar with them as a result of their undergraduate experience. Written formative assessment was also rated very highly by students as being useful for subsequent assessment preparation (91 percent). Again, this is not unexpected given the responses by students indicated in Table 1, suggesting
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that students found the first written formative assessment gave them an indication of the breadth and depth of knowledge required, and that 91 percent of students expect to change their approach to study as a result of their first assessment. Students reported in the focus group that “we found out what we needed to know; how to manage time during the assessment; the marking system.” In other words, the written formative assessment is utilized by students as a learning aid in that it teaches them how to approach subsequent exams and how much study and knowledge they feel are required by the course. Interestingly, clinical days were also rated highly by students as useful for preparing for assessments. A special feature of the University of Sydney B.Dent. program is the exposure of students to dental skills, both preclinical and clinical, very early in the program. This finding suggests that students value this exposure and can already see the relevance of the clinical setting to their content-based examinations. However, students are also assessed formatively and summatively on their clinical competencies, so perhaps this agreement reflects the usefulness of clinical days in preparing for clinical assessments rather than written assessments. In future studies this question could be addressed further. Students provided mixed responses about the usefulness of theme sessions (sessions that addressed ethical and philosophical issues relevant to various cases presented) and independent study groups in preparing for assessments. Fifty-three percent of students thought the theme sessions were useful, and 47 percent did not. The fact that almost half the students did not find theme sessions helpful in preparing for assessments was analyzed further by examining correlations with approach to learning. Interestingly, students who indicated a surface approach to learning did not find theme sessions useful for preparation for assessment or preparation to be a dental clinician (see Table 3). It is possible also that the content of theme sessions are far more difficult to adequately assess in integrated written assessments and so are less valuably favored by some students. The mixed response by students regarding the usefulness of independent study groups in assessment preparation may simply be a reflection of the fact that not all students are involved in these groups, particularly at this early stage in the program. Alternatively, the correlation between approach to learning and perceived usefulness of study groups suggests that students who take a deep approach to their
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learning, as well as students who take an achievement approach to their learning, do, in fact, rate independent study groups as useful for preparation for assessments and to be a clinician (see Table 3). Students also reported finding, on the whole, most of their learning aids useful in preparing to be a clinician. Notably, PBL tutorials and clinical days were rated by all students as being useful in their preparation (100 percent agreement). Among the aims of the program are the development of clinical reasoning and problem-solving in a context of scientific and clinical knowledge; evidence-based dental clinical practice; sensitive and effective communication with patients and colleagues; and the application of an understanding of medical issues to dental problems. The features of the program particularly designed to aid in achieving these aims are the PBL tutorials and the early exposure of students to the clinical practice of dentistry. The 100 percent agreement rating by students of the usefulness of these two tools in preparing to be clinicians indicates that students appreciate their early clinical exposure and the provision of these learning aids are fulfilling faculty aims from the student perspective. A majority of students also rated learning topics, textbooks, theme sessions, and lectures as being useful in preparing to be a clinician (⊕ 65 percent agreement; see Table 2), though not as highly as PBLs and clinical days. We interpret this as suggesting that students understand the need to have a solid basis of theory in order to apply knowledge in a clinical setting, as indicated by students in the focus group who said they “need theory to apply to the clinical side.” There was a more mixed response regarding the usefulness of independent study groups and syndicate notes in preparing to be a clinician, but again this may reflect that only some of the students use these resources or student approach to learning regarding study groups as previously discussed. Online assessment and the written formative assessment were not seen by the majority of students as being useful in preparing to be a clinician. These learning aids were rated highly by students as useful for assessment preparation, and it would seem in this instance that students are differentiating between content knowledge required to pass an exam and the application of this content in a clinical setting. This is interesting as students perceived the ways in which they receive content (lectures, textbooks, learning topics, theme sessions, PBLs) as being very useful in preparing them to be a clinician. However, being
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examined on this information in the current assessment form was not perceived by students as useful in preparation to be a clinician. As already discussed, assessments were seen as useful for further assessment preparation, suggesting that students perceive assessments as a learning aid that helped them pass other assessment tasks, but do not see written assessments as aiding in their preparation to be a clinician. We also examined the correlation between the way students use their learning aids in their preparation for assessment and their preparation to be a clinician. The correlations for all learning aids other than PBLs and textbooks were high, with r values ≥ .45 (see Table 2), suggesting that overall students are not differentiating markedly between preparation for assessment and preparation to be a clinician. This suggests that students can appreciate the alignment in the course goals of content knowledge (examined by assessment procedures and provided by traditional learning aids such as lectures and textbooks) and clinical application (developed by the PBL process and clinical days). However, it is likely that these firstyear students in the first year of a new course are not as aware of clinical requirements and so cannot discern potential gaps between the course goals and the implementation of these goals. It is also possible that the highly positive results indicated here might be an artifact of this being the first-year intake of a new course. This can be clarified by further monitoring of first-year students in the B.Dent. program and tracking of these student respondents over the next few years. Textbooks and PBLs were both notable exceptions to the good correlation found between use of learning aids for assessment and use of learning aids to be a clinician. While all students see PBL tutorials as useful in preparing to be a clinician, fewer (74 percent) see them as useful in preparing for assessment. This may be attributable to both characteristics of the assessment instruments (a failure to adequately reflect the clinical reasoning process) and the approach to learning of the students. The former interpretation is supported by the fact that only 50 percent of students thought that the MEQ assessment reflected the clinical reasoning process utilized in PBL sessions. This finding may also reflect the fact that the majority of PBL cases in years one and two are primarily based in medical issues, with only highlighting of dental issues, so that there is less direct alignment of the PBL tutorials to students’ dental clinical sessions.
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Student Approach to Learning: Correlations with Perceptions of Assessment and Perception of Learning Aids A number of significant correlations were obtained, most of which were theoretically meaningful. Higher scores on a surface approach to learning were associated with a student perception that the MEQ paper was not representative of curriculum content (i.e., a focus on the assessment as a test, rather than a learning aid), that theme sessions (which are less didactic and often cover philosophical and ethical issues) were not useful either in preparation for assessment or to be a clinician, and that lectures were useful in preparing to be a clinician. A deep approach was associated with a perception that the MEQ paper tested clinical application of basic and clinical sciences, a perception that independent study groups were useful both in preparation for assessment and to be a clinician and that clinical days were useful in preparing to be a clinician. These correlations are consistent with an orientation to application of knowledge and a valuing of self-directed learning. The correlation with learning topics was less theoretically consistent and might have been expected to be associated with surface learning. Finally, an achievement orientation was associated with pragmatic responses aimed at improving performance in subsequent assessments, but there was also some overlap with a deep approach to learning. Significant correlations were found between an achievement approach and a perception that formative assessment helped clarify strengths and weaknesses, the level of knowledge and understanding required, and an intention to change the approach to study as a result reflect a pragmatic (and probably adaptive) utilization of formative assessment as a learning aid. The overlap with deep learning occurred with respect to a valuing of independent study groups and learning topics. Interestingly, there was also a significant correlation between an achievement approach and a perception of online assessment as a useful learning aid, suggesting that an achievement orientation is associated with valuing most available learning aids. In general, despite a reasonably satisfactory response rate (72 percent) amongst students, the small sample size of thirty-four students may impact on the power of these results. The findings, however, are of sufficient interest to warrant further investi-
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gation in a larger sample by extending to year two and following years.
Conclusions On the basis of the findings in this study, dental students indicate that they perceive the learning aids provided to them by faculty as well as those they developed themselves as being overall useful in both their preparation for assessments and their preparation to be dental clinicians. Students are clearly “informed” and undergo change by experiencing a PBL curriculum and its assessment, even at this early stage in their careers. These findings are of importance to curriculum developers in the Faculty of Dentistry because they document that the learning aids are actually supporting the curriculum goals. The results particularly highlight students’ specific perceptions of assessment and suggest areas that require further review. In particular, there is a need to review written assessment questions and ensure that they do, in fact, assess understanding and application rather than recall of scientific concepts. As a corollary to this, specifications regarding minimal level of competence need to be based on evidence of clinical reasoning. Student readiness to be informed and changed by the “experience” of the formative assessments to optimize their use of learning aids is a fine tribute to their level of application and maturity and is gratifying to the developers of these assessments. Our study is part of ongoing research in student perceptions of the curriculum as it progresses through the years and will enable informed reform and improvement of the curriculum, particularly in assessment styles and types. While the final “test” of the educational value of any new curriculum is likely to be, however, the valid assessment of the overall quality of the graduates by their own dental patients and the community and by independent peers in the profession, the current findings give early support and encouragement to that commitment made by faculty to reform its curriculum. The findings also have broader implications for PBL-based programs. The presentation, types, and availability of learning aids can be optimized by teachers when those most valued by students are identified. This identification also assists teachers in constructing their course outlines, particularly in the area of learning situations and assessment where direct reference can be made to the use of learning aids.
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This knowledge will likely also enhance student and teacher satisfaction in their learning and teaching and facilitate the ability of students and teachers to meet their respective goals through their shared curriculum experience. Curriculum development is a continuing and evolving process that is enormously informed by student feedback and organized studies of perceptions of learning.18,19,22 In many ways, teaching is instructed, renewed, and enhanced by constructive feedback. The current findings require committed consideration by curriculum and assessment developers in any PBL program, particularly at the seminal stage in the natural lifecycle of a dental curriculum. The current study has implications for many groups with vested interests in education in general and in dental education specifically; for the dental profession, in being informed about how the faculty develops and evaluates a curriculum that is sensitive to changes in community oral health patterns, research, and teaching; and also for the faculty itself in continuing to invest in curriculum improvement based on educational research findings. There are implications also for teachers, in planning and enacting better teaching styles informed by student perceptions, and for students, by understanding the way they change as a direct result of their learning and how to meaningfully engage with their learning.
Acknowledgments The guidance and advice of the Institute for Teaching and Learning at the University of Sydney is warmly acknowledged in the preparation and encouragement of this study during the time all four authors were preparing for their Graduate Certificate in Educational Studies (Higher Education). Most specifically, we wish to thank Dr. Christine Asmar, Dr. Kym McShane, Associate Professor Michael Prosser, Dr. Simon Barrie, and Associate Professor Angela Brew. We also wish to express gratitude for the invaluable critical review of the manuscript by Emeritus Professor Ann Sefton AO and the Dean of Dentistry, Professor Keith Lester.
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